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Ultrasound/Fetal Monitoring Requisition for BCWH HTML

HTML icon DiagnosticServicesHistoryIntakeForm.html — HTML, 24 kB (24849 bytes)

File contents

<html>

<head>

<title>DiagnosticServicesHistoryIntakeForm</title>

<script type="text/javascript" src="${oscar_javascript_path}eforms/faxControl.js"> </script>



<script language="javascript" type="text/javascript">

		/****************************

		startup functions 

		****************************/

		function startUp()

		{			

			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments

			var strLoc = window.location.href.toLowerCase();

			if(strLoc.indexOf("https") == -1)

			{

				//page1

				var src = document.getElementById('BGImage').src;				

				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');

			}

		}



		/****************************

			checkbox functions 

		****************************/

		function changeValue(x)

		{

			if (document.getElementById(x).value == '')

				document.getElementById(x).value = 'X';

			else

				document.getElementById(x).value = '';

		}



		function displayKeyCode(evt,x)

		{

			var charCode = (evt.which) ? evt.which : event.keyCode

			// any key press except tab will constitute a value change to the checkbox

			if (charCode != 9)

			{

				changeValue(x);

				return false;

			}

		}



	</script>



<style type="text/css" media="print">

 .DoNotPrint {

	 display: none;

 }

 .noborder {

	 border : 0px;

	 background: transparent;

	 scrollbar-3dlight-color: transparent;

	 scrollbar-3dlight-color: transparent;

	 scrollbar-arrow-color: transparent;

	 scrollbar-base-color: transparent;

	 scrollbar-darkshadow-color: transparent;

	 scrollbar-face-color: transparent;

	 scrollbar-highlight-color: transparent;

	 scrollbar-shadow-color: transparent;

	 scrollbar-track-color: transparent;

	 background: transparent;

	 overflow: hidden;

 }

 </style>



<script language="javascript">

function formPrint(){

			window.print();

} 

</script>



<!-- scripts to confirm closing of window if it hadn't been saved yet -->

<script language="javascript">

//keypress events trigger dirty flag

var needToConfirm = false;

document.onkeyup=setDirtyFlag;

function setDirtyFlag(){

		needToConfirm = true;

}

function releaseDirtyFlag(){

		needToConfirm = false; //Call this function if doesn't requires an alert.

//this could be called when save button is clicked

}

window.onbeforeunload = confirmExit;

function confirmExit(){

	 if (needToConfirm){

		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";

	 }

}

</script>



</head>



<body onload="startUp();">

<img id='BGImage' src="${oscar_image_path}DiagnosticServicesHistoryIntakeForm.png" style="position: absolute; left: 0px; top: 0px; width:750px">

<form method="post" action="" name="FormName" id="FormName" >



<input name="Today" id="Today" type="text" class="noborder" style="position:absolute; left:54px; top:171px; width:278px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=today>





<input name="ReferralName" id="ReferralName" type="text" class="noborder" style="position:absolute; left:153px; top:200px; width:307px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=current_user>





<input name="DrBillingnumber" id="DrBillingnumber" type="text" class="noborder" style="position:absolute; left:516px; top:200px; width:226px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=doctor_ohip_no>





<input name="DEPhone" id="DEPhone" type="text" class="noborder" style="position:absolute; left:75px; top:224px; width:153px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=doctor_work_phone>





<input name="PrivateLine" id="PrivateLine" type="text" class="noborder" style="position:absolute; left:309px; top:224px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="ReferralFax" id="ReferralFax" type="text" class="noborder" style="position:absolute; left:517px; top:224px; width:226px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=clinic_fax>





<input name="Copiesto" id="Copiesto" type="text" class="noborder" style="position:absolute; left:81px; top:253px; width:280px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=referral_name>





<input name="Billing" id="Billing" type="text" class="noborder" style="position:absolute; left:417px; top:253px; width:130px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=referral_no>




<input name="Copiesto2" id="Copiesto2" type="text" class="noborder" style="position:absolute; left:82px; top:281px; width:278px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Billing2" id="Billing2" type="text" class="noborder" style="position:absolute; left:419px; top:281px; width:128px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Yes" id="Yes" type="text" style="position:absolute; left:14px; top:311px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"> 





<input name="No" id="No" type="text" style="position:absolute; left:64px; top:311px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Appointmentdate" id="Appointmentdate" type="text" class="noborder" style="position:absolute; left:592px; top:306px; width:116px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"   value="">





<input name="Appointmenttime" id="Appointmenttime" type="text" class="noborder" style="position:absolute; left:592px; top:339px; width:116px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="m$G#value" id="oscarDB=m$G#value" type="text" class="noborder" style="position:absolute; left:38px; top:368px; width:39px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$G#value>





<input name="m$TERM#value" id="m$TERM#value" type="text" class="noborder" style="position:absolute; left:97px; top:368px; width:37px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$TERM#value>





<input name="m$PRET#value" id="m$PRET#value" type="text" class="noborder" style="position:absolute; left:154px; top:368px; width:38px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$PRET#value>





<input name="m$ECTP#value" id="m$ECTP#value" type="text" class="noborder" style="position:absolute; left:227px; top:368px; width:36px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$ECTP#value>





<input name="m$SA#value" id="m$SA#value" type="text" class="noborder" style="position:absolute; left:298px; top:368px; width:37px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$SA#value>





<input name="m$TOP#value" id="m$TOP#value" type="text" class="noborder" style="position:absolute; left:370px; top:368px; width:33px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$TOP#value>





<input name="m$LIVE#value" id="m$LIVE#value" type="text" class="noborder" style="position:absolute; left:426px; top:368px; width:36px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=m$LIVE#value>





<input name="m$LMP#value" id="m$LMP#value" type="text" class="noborder" style="position:absolute; left:109px; top:399px; width:108px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:whiter;" oscarDB=m$LMP#value>





<input name="Singelton" id="Singelton" type="text" style="position:absolute; left:219px; top:401px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Multiples" id="Multiples" type="text" style="position:absolute; left:307px; top:401px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Multiplesnumber" id="Multiplesnumber" type="text" class="noborder" style="position:absolute; left:394px; top:399px; width:54px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Unknown" id="Unknown" type="text" style="position:absolute; left:450px; top:401px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="PreviousUltrasoundNo" id="PreviousUltrasoundNo" type="text" style="position:absolute; left:301px; top:428px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="PreviousYes" id="PreviousYes" type="text" style="position:absolute; left:349px; top:428px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Previousyesother" id="Previousyesother" type="text" style="position:absolute; left:451px; top:428px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Ultrasoundbookedno" id="Ultrasoundbookedno" type="text" style="position:absolute; left:318px; top:456px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="bookedyes" id="bookedyes" type="text" style="position:absolute; left:358px; top:456px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="ultrasounddate" id="ultrasounddate" type="text" class="noborder" style="position:absolute; left:449px; top:456px; width:104px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Facility" id="Facility" type="text" class="noborder" style="position:absolute; left:606px; top:456px; width:106px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:wihte;" value="">





<input name="Obstectrical" id="Obstectrical" type="text" style="position:absolute; left:14px; top:542px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Fetal" id="Fetal" type="text" style="position:absolute; left:14px; top:561px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="AFI" id="AFI" type="text" style="position:absolute; left:14px; top:580px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Nuchal" id="Nuchal" type="text" style="position:absolute; left:14px; top:599px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Nonob" id="Nonob" type="text" style="position:absolute; left:14px; top:618px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="FetalM" id="FetalM" type="text" style="position:absolute; left:14px; top:637px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Routine" id="Routine" type="text" style="position:absolute; left:413px; top:545px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Growth" id="Growth" type="text" style="position:absolute; left:413px; top:567px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="PostDates" id="PostDates" type="text" style="position:absolute; left:413px; top:589px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="OtherInd" id="OtherInd" type="text" style="position:absolute; left:413px; top:611px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="OtherIndications" id="OtherIndications" type="text" class="noborder" style="position:absolute; left:476px; top:608px; width:236px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="NonObSpecify" id="NonObSpecify" type="text" class="noborder" style="position:absolute; left:249px; top:617px; width:149px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<textarea name="PertinentInformation" id="PertinentInformation" class="noborder" style="position:absolute; left:20px; top:684px; width:695px; height:61px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" ></textarea>





<input name="48" id="48" type="text" style="position:absolute; left:109px; top:747px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="within7" id="within7" type="text" style="position:absolute; left:190px; top:747px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="PleaseBook" id="PleaseBook" type="text" style="position:absolute; left:301px; top:747px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Bookat" id="Bookat" type="text" class="noborder" style="position:absolute; left:415px; top:748px; width:93px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Referofficeyes" id="Referofficeyes" type="text" style="position:absolute; left:13px; top:829px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="ReferOfficeNo" id="ReferOfficeNo" type="text" style="position:absolute; left:64px; top:829px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Please" id="Please" type="text" style="position:absolute; left:23px; top:851px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="CareCardcheck" id="CareCardcheck" type="text" style="position:absolute; left:23px; top:876px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Prepcheck" id="Prepcheck" type="text" style="position:absolute; left:23px; top:890px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="DirectionsCheck" id="DirectionsCheck" type="text" style="position:absolute; left:23px; top:905px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Webcheck" id="Webcheck" type="text" style="position:absolute; left:23px; top:920px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Scentcheck" id="Scentcheck" type="text" style="position:absolute; left:23px; top:936px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Womencheck" id="Womencheck" type="text" style="position:absolute; left:23px; top:951px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="Photocheck" id="Photocheck" type="text" style="position:absolute; left:23px; top:967px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">





<input name="USPN" id="USPN" type="text" class="noborder" style="position:absolute; left:532px; top:884px; width:167px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Cerner" id="Cerner" type="text" class="noborder" style="position:absolute; left:496px; top:909px; width:204px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Triaged" id="Triaged" type="text" class="noborder" style="position:absolute; left:453px; top:935px; width:247px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="GA" id="GA" type="text" class="noborder" style="position:absolute; left:411px; top:960px; width:57px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="EDD" id="EDD" type="text" class="noborder" style="position:absolute; left:522px; top:960px; width:62px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<input name="Initials" id="Initials" type="text" class="noborder" style="position:absolute; left:638px; top:960px; width:62px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">





<textarea name="Label" id="Label" type="text" class="noborder" style="position:absolute; left:422px; top:15px; width:320px; height:179px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=label></textarea>









 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:985px; left:0px;">

	 <table><tr><td>

		 Subject: <input name="subject" size="40" type="text"> 

			<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick=" releaseDirtyFlag();"> 

			<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 

			<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="formPrint();"> 

			<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 

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